Perceptions of chief clinical information officers on the state of electronic health records systems interoperability in NHS England: a qualitative interview study

Abstract

Background

In the era of electronic health records (EHR), the ability to share clinical data is a key facilitator of healthcare delivery. Since the introduction of EHRs, this aspect has been extensively studied from the perspective of healthcare providers. Less often explored are the day-to-day challenges surrounding the procurement, deployment, maintenance, and use of interoperable EHR systems, from the perspective of healthcare administrators, such as chief clinical information officers (CCIOs).

Objective

Our study aims to capture the perceptions of CCIOs on the current state of EHR interoperability in the NHS, its impact on patient safety, the perceived facilitators and barriers to improving EHR interoperability, and what the future of EHR development in the NHS may entail.

Methods

Semi-structured interviews were conducted between November 2020 – October 2021. Convenience sampling was employed to recruit NHS England CCIOs. Interviews were digitally recorded and transcribed verbatim. A thematic analysis was performed by two independent researchers to identify emerging themes.

Results

Fifteen CCIOs participated in the study. Participants reported that limited EHR interoperability contributed to the inability to easily access and transfer data into a unified source, thus resulting in data fragmentation. The resulting lack of clarity on patients' health status negatively impacts patient safety through suboptimal care coordination, duplication of efforts, and more defensive practice. Facilitators to improving interoperability included the recognition of the need by clinicians, patient expectations, and the inherent centralised nature of the NHS. Barriers included systems usability difficulties, and institutional, data management, and financial-related challenges. Looking ahead, participants acknowledged that realising that vision across the NHS would require a renewed focus on mandating data standards, user-centred design, greater patient involvement, and encouraging inter-organisational collaboration.

Conclusion

Tackling poor interoperability will require solutions both at the technical level and in the wider policy context. This will involve demanding interoperability functionalities from the outset in procurement contracts, fostering greater inter-organisation cooperation on implementation strategies, and encouraging systems vendors to prioritise interoperability in their products. Only by comprehensively addressing these challenges would the full potential promised by the use of fully interoperable EHRs be realised.

What is already known on this topic

Although Electronic Health Record (EHR) deployment in the National Health Service (NHS) has steadily increased, interoperability between healthcare facilities has remained problematic. Despite numerous policy initiatives aimed at tackling this issue, little success has been found in rectifying this issue to improve effective data sharing.

What this study adds

Our study captured the current state of EHR interoperability and its perceived facilitators and barriers from a unique and often underrepresented perspective: Chief Clinical Informatics Officers (CCIO). CCIOs have noted several facilitators toward interoperability, including the recognition of need from clinicians, expectations from patients, and the inherently centralised arrangement of the NHS itself. CCIOs have also highlighted a range of issues precluding the NHS from achieving greater EHR interoperability, from local issues including poor systems usability and data management, to more systemic ones such as institutional barriers, and financial obstacles. Accumulating EHR experience, coupled with the COVID-19 pandemic, has accelerated a renewed sense of urgency towards prioritising interoperability. Future efforts to improve EHR interoperability should anticipate emerging themes such as patients’ role in their EHR data and facilitating more effective inter-organisational collaboration across the NHS.

How this study might affect research, practice, or policy

Our study aims to inform on the establishment of more relevant, sustainable and cost-effective approaches to implementing and utilising interoperable EHR systems in the NHS. Targeted health technology policies addressing the identified limitations will help both make existing systems safer and streamline care delivery. Accomplishing this will allow such systems to evolve and better meet the changing healthcare needs confronting the NHS in the coming years.

Introduction

Background

Since the early 2000s, electronic health records (EHR) have played an increasingly integral role in the clinical environments of most high-income countries [1,2,3,4]. Many of the purported benefits of EHR (i.e., more effective care coordination, communication between providers, lower healthcare costs, improving patient safety), rely upon the effective exchange of information between various systems [5,6,7,8,9,10].

Interoperability, defined as ‘the ability for clinical data to be shared seamlessly between differing EHR systems without loss of context and for the data to be usable in a coordinated manner to facilitate patient care’, has continued to be a growing challenge [7, 11, 12]. Due to the inherent technical complexity and nature of the clinical information involved, interoperability between existing systems varies greatly in both availability and sophistication [13, 14].

The Healthcare Information and Management Systems Society (HIMSS) categorises interoperability into three tiers: (1) foundational interoperability, (2) structural interoperability, and (3) semantic interoperability [12, 15,16,17]. Foundational interoperability describes ‘the inter-connectivity requirements needed for one system or application to securely communicate data to and receive data from another’ [12, 15]. Structural interoperability refers to information exchange between health information technology (HIT) systems at the data field level, made possible using common data formats, syntax, and organisational standards [12, 17]. Semantic interoperability, the most complex of the three levels, describes the use of open standards (e.g., Fast Healthcare Interoperability Resources (FHIR) or Health Level Seven (HL7)) for codifying data elements (i.e., content, terminology, and security to enable a shared understanding of clinical data) [7, 12, 15]. It should be noted, however, other definitions which stratify levels of interoperability in greater detail (such as technical, syntactic, pragmatic, dynamic, conceptual, structural, functional, and semantic interoperability), have also been proposed in recent years [18].

There are various approaches globally to improve interoperability, with varying levels of success. In the United States, the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act and accompanying Meaningful Use programme aimed to incentivise EHR integration and the establishment of more robust health information exchanges [5, 19,20,21]. In the subsequent years, for-profit healthcare delivery systems (i.e., Kaiser Permanente), successfully introduced integrated HIT across hospitals, community-based clinics, pharmacies, and laboratories [22,23,24]. Similar efforts were undertaken in Canada, Demark, and Saudi Arabia [4, 24, 25].

In the United Kingdom, the 2002 National Programme for IT (NPfIT) attempted to introduce a centralised EHR system with integrated electronic patient records, appointment scheduling, patient referrals, and prescription renewal systems by 2010 [2, 10, 26,27,28], but the initiative was eventually cancelled in 2011, due to financial and implementation issues [10, 24, 27, 28]. The UK continued funding similar efforts aimed at establishing integrated EHRs [29, 30] but, to date, these efforts resulted only in the establishment of modest regional networks with limited interoperability [24, 27, 28, 31].

Research on EHR interoperability has traditionally been US-centric and focused on provider perspectives [29, 32,33,34,35]. Potential benefits identified included greater data accuracy and easier access to information, and improved efficiency and timeliness of care [19, 35, 36]. Potential barriers have also been reported, including high costs, organisational barriers to change, mixed provider satisfaction, technological hurdles, and data overload for users [36,37,38]. Less attention has been paid to investigating the pragmatic challenges to interoperability from the perspective of other stakeholders in the health system (i.e., healthcare administrators), as well as their consequences on patient safety. In the UK, Chief Clinical Informatics Officer (CCIO) is a senior role which ‘provides leadership and management of ICT (information and communications technologies) and information development activity to support the safe and efficient design, implementation and use of informatics solutions to deliver improvements in the quality and outcomes of care’ [39,40,41,42]. CCIOs usually are clinicians (i.e., doctors, nurses, pharmacists) who also possess clinical informatics expertise, training, and experience and are involved in introducing, using, and maintaining HIT systems. As such, ascertaining their unique perspective regarding the present state of EHR interoperability in the NHS would be beneficial to highlight administrative and grass-roots level interoperability challenges and describe how they impact patient safety in NHS settings.

Aim and objectives

This study aims to gain a better understanding of EHR interoperability and its impact on patient safety from the perspective of CCIOs. Specific objectives include:

• 1. Capture the perceptions of CCIOs regarding the current state of EHR interoperability.

• 2. Assess its perceived effect on patient safety.

• 3. Investigate facilitators and barriers to achieving interoperability.

• 4. Explore perceptions on how the evolution of EHR interoperability would improve patient safety in the coming decade.

Methods

Semi-structured, in-depth, 1:1 online interviews were utilised due to its ability to explore participants’ thoughts, feelings and beliefs about a given topic, delving into their personal experiences [43]. Interviews were conducted between November 2020 – October 2021 using a standardised topic guide (Supplement 1) and lasted 45–60 min. The interviews were digitally recorded and transcribed verbatim. No repeat interviews were conducted.

Study population

The study population of interest were CCIOs based in NHS England primary and secondary healthcare facilities, from various clinical backgrounds (i.e., doctors, nurses, pharmacists). Participants must have had at least one year of experience working with EHR systems in NHS settings in England. Only English speakers were included.

Participant recruitment

Participants were identified using the NHS Digital Academia Alumni network, and snowball sampling was subsequently used to increase the sample. CCIOs who met the inclusion criteria were invited to participate via email.

Data analysis

Audio recordings were transcribed and thematically analysed by two researchers independently (EL, OL). The analysis was both deductive and inductive in its approach. Regular meetings between the lead researcher and other members of the research group took place to assess data saturation, ensure coding quality, and refine the codes and subthemes. Microsoft Excel and Miro were used to organise codes and resultant themes.

Results

A total of 15 NHS England CCIOs were interviewed. For characteristics of the study participants, please see (Table 1). Five main emergent themes and their respective subthemes were mapped (Fig. 1).

Table 1 Study participant characteristics

Fig. 1

Mapping of prominent themes identified

Perceptions on the current state of EHR interoperability in the NHS

Amongst participants, there is a lack of consensus regarding what interoperability entails (Table 2). For some, interoperability meant simply being able to access a recent GP letter scanned in PDF form; for others, it meant being able to trace a patient’s trajectory of care through their last hospital stay, including clinical notes and laboratory results.

Table 2 Current state of EHR interoperability

Information sharing between primary and secondary care, and between different clinical specialties remains especially problematic, particularly concerning sensitive information (e.g., mental health conditions). The level of data transferrable or accessible also varies greatly between medical staff and allied health teams. Limited data exchange abilities result in substantial patient data fragmentation, data quality issues, and suboptimal clinical workflows.

CCIOs reported that when procuring EHR systems, the importance of interoperability with other healthcare facilities was often only recognised after implementation.

Perceived impact on patient safety

Many participants noted that limited EHR interoperability often contributed to longstanding issues concerning EHR data quality which negatively impacted patient safety (Table 3).

Table 3 Perceived impact on patient safety

One shortcoming resulting from the lack of interoperability is the inability to easily access and transfer data into a unified source; participants perceived this to be detrimental to patient safety as they do not have clarity regarding the patient’s overall clinical status with which to base their clinical decision-making on. Participants also noted that lack of interoperability results in data fragmentation in several sources, and information being presented in a format that is not easily accessible, and in non-standardised formats.

Together, these aspects culminate suboptimal care planning and coordination (e.g., end-of-life care, do-not-resuscitate orders), and increased administrative workload. A frequently cited example is the difficulty of determining an accurate list of the patient’s most current medications or life-threatening allergies, particularly during transitions of care despite knowing the information is likely available elsewhere or with another provider along the patient’s care pathway.

To mitigate these patient safety issues resultant at least in part due to poor interoperability, clinicians often had to duplicate their efforts (i.e., corroborate information with patients, over-reliance on patient recollection, triangulation of information from different sources). Participants also reported that clinicians often acted more defensively (e.g., ordering duplicate diagnostic investigations) in fear of missing pertinent information and potentially leading to patient harm, for which they could be liable.

Divergent views

One participant noted that while the lack of EHR interoperability did result in him needing to search for missing information, he saw this as merely an inconvenience, but not a patient safety concern overall. However, the participant also acknowledges that this view likely differs depending on the provider’s training/specialty, with specialists (e.g., A&E, medicine subspecialities) more inclined to repeat investigations on admission due to their accessibility in the hospital, compared to GPs in community clinics. Other participants questioned how useful EHR interoperability may be in practice when they often still prefer to refer to their own notes as a ‘trusted source’.

Facilitators of EHR interoperability

Study participants highlighted several facilitators to achieving greater EHR interoperability, which can be broadly organised into three subthemes (Table 4): (1) recognition of need and possibility amongst healthcare workers (2) expectation from patients, and (3) centralised nature, strategic levers, and national oversight.

Table 4 Facilitators of EHR interoperability

Recognition of need and possibility amongst healthcare workers

Participants noted that COVID-19 accelerated the deployment of digital solutions (e.g., non-paper-based tools), exposing some of the tangible benefits of interoperability and raising awareness on the topic. In the past, frontline workers prioritised EHR functions that would influence their own workflows without acknowledging their impact on larger interoperability initiatives. Working across various organisations has highlighted the need to think holistically about interoperability and prompted workers to reflect on its state at their own organisations.

Expectation from patients

As a result of poor EHR interoperability, healthcare providers are often less familiar with their patient’s information than what patients typically expected. This required providers to rely on patient-provided information and thus potentially negatively impact patient satisfaction and trust. Participants acknowledged that unmet patient expectations are strong motivators for efforts to improve interoperability.

Centralised nature, strategic levers, and national oversight

The UK was perceived to be ideally positioned to be a global leader in healthcare interoperability because of its centralised organisational structure and single organisational identity as the NHS. As workflows are relatively similar between organisations, there is increased potential for standardisation of data handling processes in pursuit of wider interoperability. Participants noted that interoperability is increasingly prioritised for discussion in multiple forums.

Barriers to achieving EHR interoperability

Barriers identified can be organised into four subthemes (Table 5): (1) systems usability, (2) institutional, (3) data-related, and (4) vendor/finance-related barriers.

Table 5 Barriers to achieving EHR interoperability

Poor EHR systems usability

Most frontline healthcare providers reported negative experiences using EHRs to retrieve information from other organisations. Interoperability was described as being only able to share a narrow set of data rather than comprehensive records. Participants noted the need for external portals or multiple logins to access records from other organisations, though small hindrances alone, culminated in an incohesive user experience and a negative perception of efforts to achieve interoperability.

Institutional barriers

While healthcare providers are often frustrated with poor interoperability, they are seldom involved in improvement efforts. While the presence of the CCIO role does help to bridge the gap between clinical and administrative staff, participants often felt the scope of interoperability issues they faced are too great to be addressed with local resources.

Several CCIOs acknowledged that there is an underlying reluctance to cooperate with nearby facilities due to their unwillingness to make substantial changes to their own EHR systems. This is mostly due to fear of disruptive changes that might require retraining or disrupt existing workflows. Some perceived that their organisation may not benefit in an equal way when compared to other organisations involved, thus making the effort not worthy of the investment.

Data management-related barriers

Participants identified that effective inter-organisational information sharing relies on the creation of accurate, structured data by clinicians. Often, they felt that incentives to provide structured data varied widely between clinicians. Some participants felt clinicians who worked within the same organisation for a long period of time or were involved in the long-term care of patients (e.g., in primary care) had greater incentives to invest their time in recording data to a higher standard. Some participants attributed variable data management to high clinical workloads and the lack of financial incentives for high-quality data management.

Finance and business-related barriers

Most participants indicated that there is often a lack of a clear business case for EHR system vendors to incorporate interoperability. Most systems are currently designed to inhibit data sharing with competing vendors’ EHR systems. Participants felt vendors appeared to be more content with using their existing systems in some hospitals to motivate neighbouring trusts to adopt the same system to achieve interoperability. Some participants, particularly those working in larger, urban trusts, suggested that coordinated procurement of the same EHR system by neighbouring trusts is the most pragmatic approach. Participants also pointed to a lack of a national plan to enhance interoperability through coordinated procurement of EHR systems.

Future of EHR interoperability

Almost all participants described a future of tighter integration between disciplines where interoperability will continue to grow in importance. They described the growing desire to access clinical data generated by other providers across primary, secondary and community care settings, with some envisaging the opportunity to also write data to these record systems. Participant responses regarding the future of interoperability fell into four main subthemes (Table 6): (1) the need for common data standards, (2) to address existing EHR systems usability issues, (3) to incorporate patients in accessing their clinical records, and (4) the need to promote greater inter-organisational collaboration.

Table 6 Future of EHR Interoperability

Need for common data standards

Implementing data standards was a near-universal need highlighted by study participants. The implementation and adherence to standards should not be limited to immediate clinical vocabulary found within EHRs but needs to include communication tools between providers, mechanisms for patient consent, and built-in for new technologies to be added in the future.

Rethinking EHR systems design: usability, automation, and innovation

Participants indicated that greater application of user-centric design principles is required to improve interoperability. With more intuitive user interfaces that are better aligned with clinician workflows, user errors, and risks to patient safety can be potentially minimised.

Participants described the potential for the use of novel technologies including artificial intelligence to automate manual data entry processes and remove administrative burdens currently required to improve interoperability. Other potential benefits of automation include improving care timeliness, data accuracy, and overall quality and relevance of clinical information in EHRs.

Patient involvement and contribution to health data

Participants identified the need to engage patients in the management of their own clinical data. This was perceived to both improve EHR data reliability, facilitate better communication between clinicians and patients, and empower patients to have more control over their own care. Other indirect benefits postulated included the reduction of workload for healthcare providers by enabling remote monitoring of patients with smart devices integrated into EHRs and reducing the need to repeat investigations and history taking due to incomplete or inaccurate documentation found within the EHRs.

Participants identified that making EHRs accessible to patients would require a significant redesign of EHR interfaces, but many felt these improvements could also make systems more useable for clinicians. While most participants supported patients having greater access to their own data, opinions differed as to whether this should include the opportunity to write into their own records.

Greater inter-organisational collaboration

Participants identified greater inter-organisational collaboration as a key aspect for the future of interoperability and emphasised the importance and value of coordinating tasks and allocating appropriate resources between organisations. Similarly, the currently often duplicative EHR improvement efforts happening across organisations could be minimised by having greater visibility and alignment of similar initiatives already taking place nearby.

Discussion

Summary of principal results

At present, EHR interoperability across NHS facilities remains largely intra-organisational, patchy, and incomplete. The interviewed CCIOs demonstrated a rather narrow interpretation of the various types of levels of interoperability and its perceived value, with captured views primarily focussed on information sharing only within their own immediate healthcare setting and/or with nearby GPs. Additional information sharing with private service providers, or incorporating patient-generated information, social care, or welfare service providers, did not seem to factor into CCIOs’ perception of the value of greater interoperability.

Initiatives aimed at improving interoperability are gradually developing, but largely remain limited in scope, sophistication, and prevalence. CCIOs are often hindered by the introduction of solutions in a piecemeal, uncoordinated fashion, and without the support and vision necessary to coherently improve EHR interoperability at regional or national levels.

Limited EHR interoperability has important patient safety implications. The inability to easily access and transfer data into a unified source contributes to data fragmentation and lack of clarity on patients' overall health status. This results in suboptimal care planning and coordination, duplication of efforts, and more defensive practice. However, a minority of participants also expressed opposing views, noting that poor interoperability posed a threat to clinician productivity rather than to patient safety directly.

Our study demonstrated that the advantages of enabling greater interoperability are evident and commonplace in the NHS. The widespread recognition of the need for interoperability amongst healthcare workers, patient expectations, and the centralised structure of the NHS itself, were all identified to be facilitators to further encouraging future interoperability efforts both within and across facilities. Challenges noted include poor usability of many EHR systems in service, as well as various institutional, financial, and data management-related barriers.

Looking ahead, however, most participants expressed a positive outlook regarding the future of interoperability in the NHS. The mandating of common data standards and interoperability functionality in procurement contracts, a greater focus on improving EHR systems design and usability with an emphasis on interoperability from the outset, strengthening the role of patients concerning their own health data within EHRs, and tackling inter-organisational collaboration barriers, were all main themes highlighted.

Strengths & limitations

To the best of our knowledge, this is the first study to investigate thoroughly the views and perceptions of NHS healthcare administrators with clinical roles surrounding the topic of interoperability and patient safety in relation to EHR implementation and use. The interviewed CCIOs came from a diverse range of clinical backgrounds working in NHS facilities across England. The interview topic guide evaluated the subject comprehensively and was developed by a multidisciplinary team based on evidence found in the wider literature. The overall study design was done in accordance with the COREQ best practice guideline [44]. The findings were coded by two qualitative researchers with backgrounds in clinical medicine, public health, and patient safety.

However, our findings must be interpreted in the context of certain limitations. Firstly, the recruitment method employed did not allow for a representative sample of CCIOs across the whole of England to be obtained. Self-selection bias is expected to be present as CCIOs agreeing to participate are likely those who are either more enthusiastic about research or have more controversial views regarding the topic and are more willing to share it. The relatively small sample size overall may also impact the external validity of our findings given the varied clinical environments found across England and other high-income countries. The inability to interview participants in person due to COVID-19 restrictions may also negatively impact the quality/richness of their responses and present some level of recall bias. However, this may be offset by its convenience and some participants finding it less intimidating to be interviewed remotely and thus more able to speak freely. Lastly, the shifting needs resulting from the COVID-19 pandemic may have both influenced what informed participants’ perceptions of the EHRs described during our interviews, as well as what may have been omitted.

Comparison with prior work

Many of the themes and subthemes identified by our study participants mirror findings from the wider EHR literature.

The advantages of using interoperable EHRs are well-documented [8, 29, 45,46,47]. While many studies pertained to clinical staff, the findings were largely in line with benefits recognised by CCIOs in our study as well [19]. Primary benefits included greater healthcare provider productivity, communication & care plan coordination between providers, and enhancing overall care quality & safety [8, 36, 45, 47]. In addition to immediate clinical uses, there are also secondary benefits identified in the literature [46,47,48]. Sandhu et al., highlighted the value of EHRs to public health (e.g., communicable disease surveillance), care quality management, medication & device safety, optimising of health systems management and notably, clinical research [49]. Nordo et al., highlighted that the use of EHR data has been demonstrated to “streamline clinical research processes at health institutions, improve data quality by reducing the number of transcription errors, support the evaluation of research protocols feasibility and increase the availability of patients to participate in research” [46, 50]. The authors also remarked, however, that the true research potential possible was curtailed by limited interoperability [46].

Likewise, many of the barriers to achieving greater EHR interoperability described by our study participants were also not entirely unexpected. For example, the problem of poor usability of EHR systems corroborates with findings from existing studies [51, 52]. A recent publication by Adams et al., concerning computerised provider order entry (CPOE) systems used alongside EHRs in many hospital settings, found that usability problems contributed to nearly 97% of medication-related errors, with data entry and workflow support being the two most common types of usability issues [53]. Similarly, other design limitations such as the failure to support clinical workflow and unresponsive/slow systems have also been previously recognised [54,55,56]. In a systematic review by Mello et al., the lack of consensus regarding terminology, classification, communication, and data transfer standards, all well-recognised problems, remain notable hurdles to interoperability today [17].

Many of the suggested solutions mentioned by our participants have also been proposed in one form or another in the existing literature. Prioritising EHR interoperability from the outset, mandating data exchange standards, promoting user-centric design & systems usability, discouraging vendors from establishing proprietary data exchange networks, and the involvement of end-users in the design and implementation process, were all concepts previously identified [17, 57,58,59]. At the organisational level, this can range from providing greater financial incentives for inter-organisational collaboration and reducing competing interests to cooperation, to simply improving communication and raising awareness of similar HIT initiatives nearby [17, 60]. The growing recognition of the importance of increasing patient involvement in their EHR data was also borne out by the recently updated NHS guidance detailing the new channels with which patients can access their GP records [61].

Implications for policy and future research

Past attempts by various stakeholders independently trying to solve interoperability through incremental measures such as developing new portals to remotely access a limited set of clinical parameters, typically do not solve the problem of poor interoperability and seldom lead to a meaningful improvement in patient safety. Instead, there needs to be a concerted effort at an individual, technical, organisational, and even national level to bring about meaningful EHR interoperability in the NHS.

At the individual healthcare provider level, formalised teaching on EHR usage starting in their undergraduate medical education and refresher training throughout their residency years may help instil a more standardised approach to handling healthcare data amongst the profession, akin to other basic skills such as history-taking and prescription writing. From the technical perspective, EHRs will likely benefit from leveraging human factors expertise and incorporating greater clinician feedback to better align EHRs with evolved user needs and expectations. At the organisational level, policies aimed at raising awareness of HIT implementation initiatives in nearby trusts would help mitigate the tendency for siloing, reduce duplicate costs/efforts, and culminate in more a coordinated, coherent implementation of HIT systems. A simultaneous re-evaluation of existing policies which may inadvertently perpetuate perverse incentives to hoard clinical data and generate artificial barriers, such as performance metrics for individual trusts, is also necessary to cultivate an environment for collaborative efforts to take place. At the greater regional or national level, mandating the use of common data standards for interoperability at the point of EHR procurement and renewal is key – preferably well-established ones already validated and in use in other countries’ healthcare systems. The fact that many providers are often ‘locked in’ to a particular vendor’s products will likely require regulatory intervention and financial incentives to discourage such business practices. Health systems from countries with smaller populations have demonstrated how this could potentially be achieved. In Finland for example, legislation concerning EHR products has mandated common interoperability standards, testing, and certification processes [62]. Relevant health information systems and exchanges were incrementally rolled out since 2010, culminating in data being seamlessly transferrable between healthcare providers, pharmacies, and patient-accessible EHRs [62]. A similar approach can perhaps be adapted for the NHS context in future EHR interoperability improvement endeavours.

Existing EHR research has often centred on outcome measures such as adoption rates, potential cost/time-savings, or end-user issues such as usability and convenience [51, 55, 63,64,65,66,67]. While these efforts were valuable in monitoring EHR implementation progress, our study has highlighted the importance of following up with studies which capture the quality of such efforts and the practical challenges confronted by other health systems stakeholders. As demonstrated, some barriers may not appear in key performance indicator metrics or are easily quantifiable, but nonetheless are present across many healthcare settings and influential to the success or failure of implementing interoperable EHRs and realising their purported benefits. Future research efforts must be devoted to other healthcare workers involved along a patient’s care pathway, EHR system vendors, policymakers, and patients & caregivers themselves. Better understanding these practical barriers can help inform the development of more relevant and effectual HIT policies and hasten the realisation of interoperability in a more cohesive manner.

Conclusion

Despite the growing prevalence of EHRs in the NHS, interoperability between systems across different healthcare settings and providers remains suboptimal. While numerous and convoluted, barriers are primarily not technical but rather institutional or business-sided (i.e., lack of sufficient political support, unclear national data standards, inadequate development of robust health information exchanges, and insufficient financial incentives to prioritise EHR interoperability).

Solutions will likely require a concerted effort from a multitude of approaches. Future efforts must focus on mandating the implementation of common data standards, tackling systems usability issues with end-users, and taking into greater consideration the growing role of patients and their ability to access and contribute to their own health information found within EHRs.